After 2 great weeks off, it was back to clinic, and meetings, and all the other stuff. And we've entered into January, my least favorite month. Cold and dark. But there is one thing I do like about January--the stream of data that hits my desk and the review of trends for our annual report. Today I received the hand hygiene data for 2010. Our group captured over 50,000 hand hygiene opportunities last year, a record for us. And our observers did this with the great app,
iScrub, created by
Phil Polgreen at Iowa. Overall compliance was 92%; 94% for nurses, and 85% for doctors. Not bad!
What percent of opportunities were on evenings? Nights? Weekends? How do you know the data is valid? My experience suggests this data is far less valid than other surveillance activities such as clabsi rates. I bet most 90% HH compliance rates reported are actually 65%. Just subtract 25%.
ReplyDeleteOur observer program schedules observers so as to cover all shifts and all areas of the hospital. Some of our observers are students (who are in class during the day), so off shifts and weekends do get covered. As for validity, with direct observations there is always likely to be Hawthorne effect. However, being on service a fair amount puts me all over the hospital and my own observation is that most of the time the person hitting the foam dispenser didn't stop to think about it (i.e., it's become reflexive)--in fact, it literally doesn't even break their stride, as they walk and foam at the same time. And I think our HAI rates are a reflection of effective hand hygiene. In our 3 largest ICUs, where we have long-term trended data on MRSA device-related HAIs, we've seen a 95% reduction since 2003 (don't have 4th quarter data yet, but for the first 3 quarters of 2010, there were 2 MRSA infections). The CLABSI rate across all ICUs is now <1.0/1000 line days. I don't think we could achieve these low rate without effective hand hygiene. So whatever the true compliance rate of HH is, it appears to be high enough to produce good effects.
ReplyDeleteWe are keenly interested in the observer effect related to the measurement of hand hygiene at Duke. We recently looked at data stored in our on-line performance database (that contains approximately 70,000 observations over an 18 month time period). We looked at several things:
ReplyDelete1) Did the compliance rate change AFTER an observer arrived in a unit?
2) Did rates of compliance change more after observers arrived on low- performing units than high-performing units.
2) How did the physical presence of observers effect HH compliance rates of different types of HCWs
Overall rates of HH compliance were approximately 10% higher when the first observation was compared with the 10th observation on the ward...ie when we looked at just the first observation on all wards/units the cumulative rate was ~82%; .when we calculated the cumulative rate using only the 10th observation, the rate was ~92%
The change in rates was substantially higher from the first to the 10th observation on poorly performing (ie in the lowest quartile) units as compared to high-performing units
The change in rates was substantially higher from the first to 10th observation for physicians as compared to other HCWs
As a result of these data we now have our observers make a maximum of 5 observations on each ward and then leave. As a result, our overall rate of HH compliance on the inpatient wards has dropped but we now believe the numbers are more accurate.
We also confirmed the observations of others by comparing a convenience sample of data collected by units that decided to designate their own (fellow workers) monitors in an effort to "check on" the accuracy of our designated HH monitors...as expected the rates reported by fellow-worker monitors was much (>10%) lower.
We have recently expanded our HH monitors to all three shifts but we still can't seem to get enough data on weekends and during the wee hours of the morning (e.g. from 10PM to 6AM) to be sure that HH compliance during these times is similar to other times. My bet is that it isn't.
Dan Sexton
Dan:
ReplyDeleteVery interesting comments. We are going to try your 5 observation rule. Also, because iScrub time stamps the observations we can look retrospectively to see if compliance increases with observation time at our hospital.
But, perhaps more interesting, this raises the question of what is the function of the HH observer program. Is it primarily to produce the most valid HH compliance rate? Or is it an intervention unto itself, raising awareness and perhaps even having a residual effect? Depending on what you believe the primary function to be, how you deploy your observers may vary.